HHS Public Access Author manuscript Author Manuscript
Ann Intern Med. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Ann Intern Med. 2016 November 1; 165(9): 650–660. doi:10.7326/M16-0652.
Preoperative Frailty Assessment and Outcomes At 6 Months or Later In Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review Dae Hyun Kim, MD, MPH, ScD1,2, Caroline A. Kim, MD, MS, MPH1, Sebastian Placide, BA3, Lewis A. Lipsitz, MD1,4, and Edward R. Marcantonio, MD, ScM1,5
Author Manuscript
1
Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
2
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
3
Albert Einstein College of Medicine, Bronx, NY
4
Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA
5
Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Abstract Author Manuscript
Background—Frailty assessment may inform surgical risk and prognosis that are not captured by conventional surgical risk scores.
Corresponding author: Dae Hyun Kim, MD, MPH, ScD, 110 Francis Street 1A, Boston, MA, 02120, Tel: 617-632-8696, Fax: 617-632-8968, [email protected]. Author contributions: •
Conception or design: DH Kim, CA Kim
•
Acquisition, analysis, or interpretation of data: All authors
•
Drafting of the manuscript: DH Kim, CA Kim
•
Critical revision of the manuscript for important intellectual content: All authors
•
Supervision: DH Kim
Author Manuscript
Author access to data: DH Kim had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Potential conflict of interest: •
DH Kim provides paid consultative services on geriatrics care to the Alosa Foundation, a nonprofit educational organization with no relationship to any drug or device manufacturers.
Previous presentations: Earlier versions of this work were presented as a poster at the Gerontological Society of America Annual Meeting, Washington, D.C., in November 2014, and at the American Geriatrics Society Annual Meeting, National Harbor, MD, in May 2015. Reproducible research statement: •
Protocol: See Data Supplement
•
Statistical Code: Not applicable
•
Data: See Appendices
Kim et al.
Page 2
Author Manuscript
Purpose—To evaluate the evidence for various frailty instruments to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCE) in older adults undergoing cardiac surgical procedures. Data Sources—MEDLINE and EMBASE (without language restrictions), from their inception to May 2, 2016. Study Selection—Cohort studies that evaluated the association of frailty with mortality or functional status at ≥6 months in patients aged ≥60 years undergoing major or minimally invasive cardiac surgical procedures. Data Extraction—Two reviewers independently extracted study data and assessed study quality.
Author Manuscript
Data Synthesis—Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (N=18388, 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low-to-low-quality evidence to use a multi-component instrument to predict mortality or MACCE. No studies examined functional status. In patients undergoing minimally invasive procedures (N=5177, 17 studies), 13 frailty instruments were evaluated. There was moderate-to-high-quality evidence to assess mobility to predict mortality or functional status. Several multi-component instruments predicted mortality, functional status, or MACCE, but the quality of evidence was low to moderate. Multi-component instruments that measure different frailty domains seemed to outperform single-component instruments. Limitations—Heterogeneity of frailty assessment, limited generalizability of multi-component frailty instruments, few validated frailty instruments, and potential publication bias.
Author Manuscript
Conclusions—Frailty status, assessed by mobility, disability, and nutritional status, can predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgical procedures. Primary Funding Source—National Institute on Aging and National Heart, Lung, and Blood Institute; there was no registration for this review.
INTRODUCTION
Author Manuscript
Approximately 500,000 cardiac surgical procedures are performed each year in the United States and more than 50% of these are performed in older adults.(1) Due to high burden of cardiovascular disease and evolution of minimally invasive surgical techniques, this number is expected to rise.(2-4) While older patients may benefit from cardiac surgical procedures, some do not survive or experience complications,(5-10) functional decline,(11, 12) and poor quality of life.(13-15) Identifying patients who are most or least likely to benefit from surgical procedures remains a significant challenge. One of the factors underlying the heterogeneity of health outcomes in older patients is the presence of frailty, which reflects an individual's reduced physiologic reserve, inability to tolerate stressful events (e.g., surgery), and vulnerability to adverse outcomes.(16) Experts have developed several instruments to measure frailty by assessing gait speed, grip strength, or deficit accumulation,(17-23) but there is no consensus on how to best measure this
Ann Intern Med. Author manuscript; available in PMC 2017 May 01.
Kim et al.
Page 3
Author Manuscript
vulnerability.(24, 25) Despite lack of consensus, accumulating evidence suggests that assessment of frailty using any validated measures provides additional information on surgical risk and prognosis not captured by traditional surgical risk assessment.(5-10) However, most surgical risk scores do not include measures of frailty.(26-29) To incorporate frailty screening in the risk assessment before cardiac surgical procedures, it is essential to evaluate the feasibility and validity of frailty instruments in this setting. If preoperative frailty status predicts mortality, functional status, and quality of life, such information will be useful to make informed decision about the procedures.
Author Manuscript
This review aims to evaluate the evidence on feasibility of frailty instruments and their validity in predicting mortality or functional status in older patients who are undergoing major or minimally invasive cardiac surgical procedures. Since several previous reviews (30-35) have reported short-term mortality and complications, we reviewed up-to-date literature on clinical outcomes at 6 months or later after cardiac surgical procedures.
METHODS We developed but did not register a protocol for the review (see Data Supplement) and prepared this report according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.(36) Data Sources and Searches
Author Manuscript
We searched MEDLINE and EMBASE for original research articles that evaluated any frailty measures in adults undergoing cardiac surgery, without language restriction, from the inception of database to May 2, 2016, using the following keywords and their variations: “aged” and “cardiac surgery” and “frailty, geriatric assessment, mobility, gait speed, muscle strength, grip strength, physical activity, exhaustion, weight loss, nutrition, cognitive function, functional status, activities of daily living” (see Data Supplement). We also examined reference list of reviews (30-35) and articles meeting inclusion criteria. Study Selection
Author Manuscript
Two investigators (C.A.K., S.P.) independently screened titles and abstracts and then texts of full-length articles passing the title and abstract screen. Disagreement was resolved by consensus involving a third investigator (D.H.K.). Original research articles published in any language were eligible if 1) the mean age of study participants was ≥60 years; 2) the surgical procedure was coronary artery bypass grafting (CABG), open valve surgery, or transcatheter valve replacement; 3) the study was a cohort study with ≥6 months of follow-up; and 4) mortality or functional status were reported according to preoperative frailty status. We considered any measures of physical function (mobility, muscle strength, physical activity, exhaustion, nutrition, balance, disability) or any combinations thereof as acceptable screening for frailty. We did not consider comorbidity or cognitive function alone as a measure of frailty if it was not combined with measures of physical function. Although 6minute walk test (6MWT) is a measure of endurance, we classified it under mobility as it is highly correlated with mobility.(37, 38) Articles were excluded if a study design other than a cohort study was used; sample size was
Ann Intern Med. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Ann Intern Med. 2016 November 1; 165(9): 650–660. doi:10.7326/M16-0652.
Preoperative Frailty Assessment and Outcomes At 6 Months or Later In Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review Dae Hyun Kim, MD, MPH, ScD1,2, Caroline A. Kim, MD, MS, MPH1, Sebastian Placide, BA3, Lewis A. Lipsitz, MD1,4, and Edward R. Marcantonio, MD, ScM1,5
Author Manuscript
1
Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
2
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
3
Albert Einstein College of Medicine, Bronx, NY
4
Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA
5
Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Abstract Author Manuscript
Background—Frailty assessment may inform surgical risk and prognosis that are not captured by conventional surgical risk scores.
Corresponding author: Dae Hyun Kim, MD, MPH, ScD, 110 Francis Street 1A, Boston, MA, 02120, Tel: 617-632-8696, Fax: 617-632-8968, [email protected]. Author contributions: •
Conception or design: DH Kim, CA Kim
•
Acquisition, analysis, or interpretation of data: All authors
•
Drafting of the manuscript: DH Kim, CA Kim
•
Critical revision of the manuscript for important intellectual content: All authors
•
Supervision: DH Kim
Author Manuscript
Author access to data: DH Kim had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Potential conflict of interest: •
DH Kim provides paid consultative services on geriatrics care to the Alosa Foundation, a nonprofit educational organization with no relationship to any drug or device manufacturers.
Previous presentations: Earlier versions of this work were presented as a poster at the Gerontological Society of America Annual Meeting, Washington, D.C., in November 2014, and at the American Geriatrics Society Annual Meeting, National Harbor, MD, in May 2015. Reproducible research statement: •
Protocol: See Data Supplement
•
Statistical Code: Not applicable
•
Data: See Appendices
Kim et al.
Page 2
Author Manuscript
Purpose—To evaluate the evidence for various frailty instruments to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCE) in older adults undergoing cardiac surgical procedures. Data Sources—MEDLINE and EMBASE (without language restrictions), from their inception to May 2, 2016. Study Selection—Cohort studies that evaluated the association of frailty with mortality or functional status at ≥6 months in patients aged ≥60 years undergoing major or minimally invasive cardiac surgical procedures. Data Extraction—Two reviewers independently extracted study data and assessed study quality.
Author Manuscript
Data Synthesis—Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (N=18388, 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low-to-low-quality evidence to use a multi-component instrument to predict mortality or MACCE. No studies examined functional status. In patients undergoing minimally invasive procedures (N=5177, 17 studies), 13 frailty instruments were evaluated. There was moderate-to-high-quality evidence to assess mobility to predict mortality or functional status. Several multi-component instruments predicted mortality, functional status, or MACCE, but the quality of evidence was low to moderate. Multi-component instruments that measure different frailty domains seemed to outperform single-component instruments. Limitations—Heterogeneity of frailty assessment, limited generalizability of multi-component frailty instruments, few validated frailty instruments, and potential publication bias.
Author Manuscript
Conclusions—Frailty status, assessed by mobility, disability, and nutritional status, can predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgical procedures. Primary Funding Source—National Institute on Aging and National Heart, Lung, and Blood Institute; there was no registration for this review.
INTRODUCTION
Author Manuscript
Approximately 500,000 cardiac surgical procedures are performed each year in the United States and more than 50% of these are performed in older adults.(1) Due to high burden of cardiovascular disease and evolution of minimally invasive surgical techniques, this number is expected to rise.(2-4) While older patients may benefit from cardiac surgical procedures, some do not survive or experience complications,(5-10) functional decline,(11, 12) and poor quality of life.(13-15) Identifying patients who are most or least likely to benefit from surgical procedures remains a significant challenge. One of the factors underlying the heterogeneity of health outcomes in older patients is the presence of frailty, which reflects an individual's reduced physiologic reserve, inability to tolerate stressful events (e.g., surgery), and vulnerability to adverse outcomes.(16) Experts have developed several instruments to measure frailty by assessing gait speed, grip strength, or deficit accumulation,(17-23) but there is no consensus on how to best measure this
Ann Intern Med. Author manuscript; available in PMC 2017 May 01.
Kim et al.
Page 3
Author Manuscript
vulnerability.(24, 25) Despite lack of consensus, accumulating evidence suggests that assessment of frailty using any validated measures provides additional information on surgical risk and prognosis not captured by traditional surgical risk assessment.(5-10) However, most surgical risk scores do not include measures of frailty.(26-29) To incorporate frailty screening in the risk assessment before cardiac surgical procedures, it is essential to evaluate the feasibility and validity of frailty instruments in this setting. If preoperative frailty status predicts mortality, functional status, and quality of life, such information will be useful to make informed decision about the procedures.
Author Manuscript
This review aims to evaluate the evidence on feasibility of frailty instruments and their validity in predicting mortality or functional status in older patients who are undergoing major or minimally invasive cardiac surgical procedures. Since several previous reviews (30-35) have reported short-term mortality and complications, we reviewed up-to-date literature on clinical outcomes at 6 months or later after cardiac surgical procedures.
METHODS We developed but did not register a protocol for the review (see Data Supplement) and prepared this report according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.(36) Data Sources and Searches
Author Manuscript
We searched MEDLINE and EMBASE for original research articles that evaluated any frailty measures in adults undergoing cardiac surgery, without language restriction, from the inception of database to May 2, 2016, using the following keywords and their variations: “aged” and “cardiac surgery” and “frailty, geriatric assessment, mobility, gait speed, muscle strength, grip strength, physical activity, exhaustion, weight loss, nutrition, cognitive function, functional status, activities of daily living” (see Data Supplement). We also examined reference list of reviews (30-35) and articles meeting inclusion criteria. Study Selection
Author Manuscript
Two investigators (C.A.K., S.P.) independently screened titles and abstracts and then texts of full-length articles passing the title and abstract screen. Disagreement was resolved by consensus involving a third investigator (D.H.K.). Original research articles published in any language were eligible if 1) the mean age of study participants was ≥60 years; 2) the surgical procedure was coronary artery bypass grafting (CABG), open valve surgery, or transcatheter valve replacement; 3) the study was a cohort study with ≥6 months of follow-up; and 4) mortality or functional status were reported according to preoperative frailty status. We considered any measures of physical function (mobility, muscle strength, physical activity, exhaustion, nutrition, balance, disability) or any combinations thereof as acceptable screening for frailty. We did not consider comorbidity or cognitive function alone as a measure of frailty if it was not combined with measures of physical function. Although 6minute walk test (6MWT) is a measure of endurance, we classified it under mobility as it is highly correlated with mobility.(37, 38) Articles were excluded if a study design other than a cohort study was used; sample size was
